Herpes Zoster Ophthalmicus: A Review for the Internist

Higher levels of social support predict lower psychological distress for Pacific peoples living in Aotearoa New Zealand

Recent research indicates that rates of psychological distress are almost 1.5 times higher for adult Pacific peoples versus non-Pacific peoples1. Leveraging data from the New Zealand Attitudes and Values Study and utilising cross-lagged regression modelling, we examined changes in psychological distress across time for adult Pacific peoples in Aotearoa New Zealand (n = 514). Our study found that experiences of psychological distress were associated with a greater likelihood of experiencing psychological distress in the future. Additionally, experiencing higher levels of social support was associated with a lower likelihood of experiencing psychological distress in the future. Our research is vital because psychological distress is a serious mental health issue, and research that signals protective factors towards psychological distress for our Pacific peoples can help in creating better mental health outcomes for our Pacific communities. Preview on terminology: We use the term Pacific peoples, which are inclusive of a group of people in Aotearoa New Zealand that have ethnic roots from many Pacific nations. Unless a research study specifically uses the term mental illness or mental disorder, the study uses the terms mental distress and mental health issues/concerns to broadly refer to diagnosis of a mental illness or any other challenges or experiences with mental health. The choice in terminology is to shift the focus away from a deficit model of health, to those that are more consistent with Pacific views of health and wellbeing1.

Orbital Myositis after Herpes Zoster Ophthalmicus: A Case Report and a Narrative Review of the Literature

Herpes zoster ophthalmicus results from the reactivation of the latent varicella zoster virus, affecting the first branch of the trigeminal nerve. In 20-70% of cases, Zoster Ophthalmicus can lead to ocular involvement, affecting various orbital structures. Orbital myositis is a rare but severe complication of herpes zoster ophthalmicus. We present a case of a 52-year-old man with no significant medical history who developed zoster-associated right ocular myositis and dacryocystitis. He was treated with intravenous acyclovir and oral steroids. A review of the literature identified 29 patients across 19 studies. The median age was 61 years, with a slight female predominance. In 55% of cases, the patients had no notable medical history. The most common presentation of myositis involved all oculomotor muscles. There were 22 cases who were treated with intravenous antiviral therapy and 19 received steroids. A full resolution of symptoms was achieved in 51.7% of patients. Zoster-related orbital myositis is a rare complication that should be considered even in immunocompetent individuals. It may occur either before or after the appearance of a vesicular rash. Magnetic resonance imaging is the preferred radiological exam for assessing orbital involvement. Intravenous antiviral therapy should be started within 72 h of symptom onset, and its combination with systemic corticosteroids appears to be an effective treatment for zoster-related ocular myositis.

Surface anatomy in dermatology: Part I-Clinical importance, diagnostic utility, and impact on medical management

This continuing medical education series reviews updated Delphi consensus surface anatomy terminology through the lens of common medical and procedural dermatology scenarios, helping to underscore high-yield points that can be readily integrated into clinical practice to support patient care. Part I of this series will discuss the current state of surface anatomy terminology in dermatology, outline implications of precise and consistent terminology, provide an illustrative overview of high-yield consensus terminology, highlight prominent landmarks that can aid in critical diagnoses, and relate the importance of precise terminology to medical management. Part II will draw upon consensus terminology to inform the management of cutaneous malignancies and support optimal outcomes in dermatologic procedures.

Clinical and demographic profile of herpes zoster ophthalmicus: A hospital-based study of 1752 Indian patients

PURPOSE

To describe the clinical and demographic profile of herpes zoster ophthalmicus (HZO) in patients presenting to a multitier ophthalmology hospital network in India.

METHODS

Cross-sectional hospital-based study included 3,004,470 new patients between August 2010 and October 2021. Patients with a clinical diagnosis of HZO in at least one eye were included. Data were collected using an electronic medical record system.

RESULTS

In total, 1,752 (0.058%) patients were diagnosed with HZO. Nearly two-thirds were male (63.76%) in the seventh decade of life (339;19.35% patients) with unilateral (98.34%) affliction. Higher prevalence was seen in patients from higher socioeconomic status (0.059%) and metropolitan geography (0.062%). Most common ocular signs included eyelid edema (44.19%), conjunctival congestion (65.69%), punctate keratopathy (23.36%), and anterior uveitis (21.22%). Of the 1,781 eyes, mild/no visual impairment was seen in 952 (53.45%) eyes, moderate in 258 (14.49%) eyes, and severe to blindness in 363 (20.39%) eyes. Oral antivirals were started within 72 h (Group A) in 361 (20.61%) patients and after 72 h in 1391 (79.39%) patients (Group B). Significantly lesser severity of ocular involvement was noted in Group A ( P < 0.00001). Surgical intervention was required in 211 (11.85%) eyes.

CONCLUSION

HZO more commonly affects males in the seventh decade of life and is predominantly unilateral. It more commonly affects those from higher socioeconomic strata and metropolitan regions. Half of the eyes have mild or no visual impairment, while others have moderate to severe impairment. Institution of antivirals within 72 h is associated with less severe involvement. Surgical intervention is warranted in a tenth of the eyes.

Bilateral Pattern Electroretinogram Abnormalities in Patients with Herpes Zoster Keratitis and Conjunctivitis

INTRODUCTION

Herpes zoster ophthalmicus (HZO) results from the reactivation of varicella zoster virus (VZV) in the ophthalmic branch of the trigeminal nerve. The inflammation caused by VZV involves multiple tissues in the eyes. Our goal is to evaluate pattern electroretinogram (PERG) changes and their relationship with corneal sub-basal nerve changes in patients with HZO.

METHODS

Twenty-two patients with herpes zoster keratitis or conjunctivitis and 20 healthy volunteers were recruited for this cross-sectional study. A PERG test was performed on both eyes of HZO patients and one eye of the healthy controls. In vivo confocal microscopy (IVCM) was also performed on both eyes of the HZO patients to detect corneal nerve damage.

RESULTS

Our results showed changes in the PERG parameters in both eyes of HZO patients compared to the healthy controls. Affected eyes showed delayed N95 peak time and decreased P50 and N95 amplitude compared to the unaffected eyes (p < 0.05, respectively). Both affected and unaffected eyes in HZO patients showed delayed P50 peak time and decreased N95 amplitude (p < 0.05, respectively) compared to controls. In HZO patients, no significant differences in each PERG parameter were found between eyes with and without corneal lesions or between eyes with and without increased Langham's cells in the corneal epithelial sub-basal layer. The IVCM images showed decreased total nerve length and number at the sub-basal layer of the epithelial cornea in affected eyes compared to unaffected eyes (p < 0.05). No significant correlation was found between total nerve length and PERG changes.

CONCLUSIONS

Our results showed that VZV-affected eyes without central cornea involvement displayed reduced N95 amplitude and prolonged P50 peak time in bilateral eyes compared to the healthy controls. Larger studies are needed to further explore the effect of HZO on the electrophysiological response of the eye and the posterior segment.

Herpes Zoster Chorioretinopathy: A Case Series

PURPOSE

To report two patients with herpetic zoster panuveitis and chorioretinopathy with choroidal hypopigmentation.

METHODS

Retrospective chart review of two patients.

RESULTS

We report a series of two patients with a history of HZO with orbital inflammation and panuveitis, who developed patchy choroidal depigmentation consistent with a choroidopathy. The lesions were extensive and involved the posterior pole and mid-periphery in both cases. Both cases demonstrated scattered areas of ellipsoid zone loss, and fluorescein angiography showed corresponding late hyperfluorescence. OCTA in one case demonstrated flow voids at the level of choriocapillaris.

CONCLUSIONS

Our series suggests that herpetic chorioretinopathy may be a relatively benign process that presents late and may involve large areas of the posterior choroid.

Herpes simplex virus, varicella-zoster virus and cytomegalovirus keratitis: Facts for the clinician

Keratitis due to Herpes simplex virus (HSK), Varicella-Zoster virus (VZK) and Cytomegalovirus remains a frequent source of concern for many ophthalmologists. They are a frequent cause of emergency consultations at eye care centers and carry the risk of permanent loss of visual acuity or visual quality and/or chronic neurotrophic keratitis, resulting in a significant decrease in the quality of life. HSK and VZK can affect the corneal epithelium, stroma, or endothelium or a combination of layers. In contrast, most cases of CMV keratitis present as isolated endothelitis (CMVE), a clinical entity that has been described within the last 2 decades. These three types of viral keratitis are characterized by a high frequency of recurrences and each new episode increases the risk of sequelae. Hence, ophthalmologists must adapt the treatment to the clinical presentation of each recurrent episode in order to mitigate the immediate consequences of viral replication and the immune response on corneal transparency. In patients with frequent recurrences, preventive long-term antiviral treatment is strongly recommended. However, in some rare cases, continuous exposure to antivirals may promote the emergence of resistant viral strains, which can be difficult to manage. In the future, the introduction of new antiviral drugs, with differing modes of action compared to current medical therapy, could be an alternative until a truly effective preventive solution, such as a vaccine, is available.

Bilateral Pupillary Involvement as a Clinical Presentation of Herpes Zoster Ophthalmicus

PURPOSE

Herpes zoster ophthalmicus (HZO) is traditionally considered as an unilateral disease. However, subclinical involvements in the contralateral eye structures are evidence, giving rise to a broader understanding of varicella-zoster virus (VZV) infection.

METHODS

We enrolled 20 eyes of 10 patients with HZO and 12 eyes of healthy controls to investigate the bilateral features of HZO patients using a hand-held pupillometer and a Cochet-Bonnet esthesiometer.

RESULTS

Maximum pupil size before constriction (INT) and minimum diameter when pupil constricts at peak (END) were significantly smaller in patients affected eyes compared with those in controls (p < .05). Interestingly, INT and END were significantly reduced in contralateral eyes of 20 affected patients and also in comparison to control group (p < .001 and p = .034 respectively).

CONCLUSION

The contralateral eyes may have subclinical involvement in patients with HZO based on significantly abnormal pupillary light reflex (PLR). Pupillometer provides a primary and convenient method to investigate the anatomy and pathology of the PLR.

Ocular effects caused by viral infections and corresponding vaccines: An overview of varicella zoster virus, measles virus, influenza viruses, hepatitis B virus, and SARS-CoV-2

Many viral infections can affect vision and the visual system. Vaccination to prevent diseases is commonplace today, acting by stimulating an immune response without developing the pathology. It involves the production of persisting antibodies against the pathogen and the activation of T cells. Certain diseases have already been eradicated by rigorous vaccination campaigns, while others are hoped to be eliminated soon. Vaccines currently available on the market are largely safe, even if they can rarely cause some adverse effects, such as ocular complications. Analyzing existing literature, we aimed to compare the pathological effects on the eye due to the most common viral infections [in particular varicella zoster virus (VZV), measles virus, influenza viruses, hepatitis B virus, and SARS-CoV-2] with the possible ocular adverse effects of their relative vaccines, in order to establish a risk-benefit relationship from an ophthalmological point of view.

Insights From the Eye for Patients With Kidney Transplant

The eye and the kidney share structural and developmental similarities on a cellular and clinical level, and they are often affected by the same disease processes. Performing an eye exam to look for signs of conditions such as hypertension and diabetes can provide a helpful window into the health of the kidney. Patients with kidney transplants (KT) are a unique population that require close monitoring. These patients are maintained on a number of immunosuppressive medications and may face complications such as medication side effects, infections, and graft rejection. Patients with KT are at higher risk of both infectious and noninfectious eye conditions related to underlying systemic disease or use of immunosuppressive medications. Screening for eye conditions is important because preserving visual function is integral to quality of life, and also because the eye exam can help with early detection and treatment of systemic conditions. Here we describe some of the common eye findings and conditions in patients with KT. We recommend that patients with KT receive annual eye exams, and we hope that the information provided here can help nephrologists become more familiar with eye findings and identify situations where a referral to ophthalmology is warranted.

A Possible Case of Varicella Zoster Virus (VZV) Meningoencephalitis in an Immunocompetent Host

The herpes zoster infection occurs in the United States, particularly targeting those who are immunocompromised, and can present with many manifestations including encephalitis. Instances of varicella zoster virus (VZV) encephalitis in immunocompetent patients have been rarely reported, but such diagnoses are becoming more frequent as detection of VZV has improved with the adoption of molecular diagnostic panels such as the BioFire Film Array meningitis panel (Salt Lake City, USA). Here, we present an interesting case of acute meningoencephalitis in an immunocompetent adult female without dermatomal neuralgia or cutaneous lesions attributable to VZV. Given many inconsistencies between the patient’s presentation and the positive polymerase chain reaction (PCR) result for VZV, we suspected our patient was infected with an undetected organism while possibly simultaneously shedding previously acquired VZV. As molecular diagnostic panels are increasingly used and have greatly improved detection of rarer etiologies of disease, we encourage clinicians to interpret results with caution.

A Case With Herpes Zoster Ophthalmicus Mimicking Delayed Complication of Rhinoplasty

Herpes zoster ophthalmicus (HZO) occurs due to reactivation of dormant varicella zoster virus infection in the ophthalmic division of the trigeminal nerve. Hutchinson's sign, a herpetic skin lesion in the nasal tip, is a predictor of ocular complications, as the nasal tip area and ocular structure are innervated by the same nasociliary nerve. Patients who present with Hutchinson's sign should be referred to an ophthalmologist due to possibility of ocular complications. Here, we present a case of a 44-year-old man with HZO that was confused with delayed rhinoplasty complication. The patient presented with nasal tip skin lesions 17 years after undergoing augmentation rhinoplasty. A graft-related infection was suspected due to operation history and skin lesions. However, surgical exploration disclosed no infection or inflammation, and serological tests revealed positive varicella zoster virus immunoglobulin M, and immunoglobulin G, antibodies. Based on these findings, the patient was diagnosed with HZO. Further, the patient received antiviral treatment with famciclovir. The lesions gradually improved with conservative treatment and became almost unrecognizable. Therefore, HZO should be considered when there is an unexplained skin lesion at the nasal tip in patients with history of rhinoplasty.

The Role of Nervous System and Immune System in Herpes Zoster Ophthalmicus Dissemination and Laterality - Current Views

PURPOSE

Herpes zoster ophthalmicus (HZO) is a sight-threatening condition that is defined as HZ involving the ophthalmic division of the trigeminal nerve. Cases of bilateral HZO in recent literature question the notion of HZO being a strictly unilateral disease. Its pathogenesis is a topic of debate and current literature on VZV dissemination lacks insight into the underlying immunology. This review focuses on novel research in immunology of HZO and aims to formulate hypotheses of spread of lesions through the CNS.

METHODS

A literature search was conducted on Entrez PubMed using the search terms "bilateral" and "herpes zoster ophthalmicus". Articles on ("Immunology" or "immune cells") and "herpes zoster ophthalmicus" were also searched for. Articles published from January 1942 to April 2020 that were in English language were included.

RESULTS

Our findings revealed that hypothesised mechanisms of dissemination causing bilateral ocular disease include transmission from nerves to vessel walls, the synergistic action of the immune and nervous systems through the action of substance P and the von Szily reaction.

CONCLUSIONS

These mechanisms may be investigated using newer models of animal experimentation. It is imperative to define the molecular mechanisms behind VZV transmission to improve methods of identification, treatment, and prevention of HZO.

External Therapy of Chinese Medicine for Herpes Zoster: A Systematic Review and Meta-Analysis

Background. Herpes zoster (HZ) is a common skin disease that has a huge impact on the quality of life of sufferers. Antiviral therapy is a conventional treatment, but it still has limitations. This review evaluates the safety and efficacy of acupuncture in the treatment of HZ. Methods. We identified randomized controlled trials from multiple electronic sources (including Embase, PubMed, Cochrane, Web of Knowledge, China National Knowledge Infrastructure (CNKI), and China Biology Medicine Disc (CBM)) and reference lists of relevant articles and extracted data and assessed risk of bias (Cochrane’s Risk of Bias tool). Pooled data are expressed as standardized mean differences (SMDs), with 95% confidence intervals (CI) (random-effects model). Results. We included 15 trials (1811 participants) comparing acupuncture to medicine. Ten studies involving 1424 patients provided these data for the meta-analysis. The results showed that acupuncture as a control group had a higher clinical cure rate than Western medicine therapy (n = 1424, 95% Cl 2.19–3.14, I2 = 0%). Eleven studies used the visual analog scale (VAS), but only nine provided specific data, which we used as a continuous variable for data extraction. The meta-analysis also showed an SMD of −2.64 (n = 646, 95% CI −3.79–1.48, I2 = 97%) which showed great heterogeneity. Meta-analysis showed a significant reduction in the incidence of PHN in those who received acupuncture compared to pharmacotherapy (OR = 0.35, 95% CI 0.04–2.86, I2 = 52%) which showed moderate heterogeneity. Economic indicators suggest that acupuncture costs less and has fewer adverse reactions. Conclusions. This review compares acupuncture therapy with conventional treatment and finds that the curative effects of acupuncture are exact, with fewer side effects. However, with the risk of bias and imprecision of the studies included, a concrete conclusion is difficult to draw. Thus, well-designed, rigorous studies are warranted in the future.

Epidermal Growth Factor Receptor Expression in the Corneal Epithelium

A properly functioning cornea is critical to clear vision and healthy eyes. As the most anterior portion of the eye, it plays an essential role in refracting light onto the retina and as an anatomical barrier to the environment. Proper vision requires that all layers be properly formed and fully intact. In this article, we discuss the role of the epidermal growth factor receptor (EGFR) in maintaining and restoring the outermost layer of the cornea, the epithelium. It has been known for some time that the addition of epidermal growth factor (EGF) promotes the restoration of the corneal epithelium and patients using EGFR inhibitors as anti-cancer therapies are at increased risk of corneal erosions. However, the use of EGF in the clinic has been limited by downregulation of the receptor. More recent advances in EGFR signaling and trafficking in corneal epithelial cells have provided new insights in how to overcome receptor desensitization. We examine new strategies for overcoming the limitations of high ligand and receptor expression that alter trafficking of the ligand:receptor complex to sustain receptor signaling.

Short-Term Peripheral Nerve Stimulation Relieve Pain for Elder Herpes Zoster Ophthalmicus Patients: A Retrospective Study

OBJECTIVE

Ophthalmic postherpetic neuralgia (PHN) is the final stage of herpes zoster (HZ) ophthalmicus and a severe refractory neuropathic pain, thus there is no curative treatment that could alleviate pain and reduce the incidence of ophthalmic PHN now. The purpose of this study is to evaluate therapeutic efficacy of short-term peripheral nerve stimulation (PNS) for elder patients with HZ ophthalmicus.

MATERIALS AND METHODS

We performed a retrospective study from March 2015 to August 2019 in our pain department. All the HZ ophthalmicus patients underwent supraorbital nerve short-term PNS were included. The patients' data, including numeric rating scale (NRS), 36-Item short form health survey (SF-36), and analgesic consumptions, were retrospectively analyzed. Severe side effects also were recorded.

RESULTS

A total of 68 patients were enrolled in this study. The NRS scores were significantly decreased at different time points after short-term PNS compared to baseline (p < 0.001). The SF-36 scores, including general health, social function, emotional role, mental health, bodily pain, physical functioning, physical role, and vitality, were significantly improved at different time points after treatment (p < 0.001). The average dosages of tramadol and pregabalin administered (mg/d) were both significantly reduced compared to baseline (p < 0.001). There was no bleeding, infection, pain increase, and other side effects after treatment.

CONCLUSIONS

Short-term PNS is an effective and safe therapeutic alternative for elder patients with HZ ophthalmicus and could reduce the incidence of ophthalmic PHN.

Practical Guidance for Clinical Microbiology Laboratories: Diagnosis of Ocular Infections

The variety and complexity of ocular infections have increased significantly in the last decade since the publication of Cumitech 13B, Laboratory Diagnosis of Ocular Infections (L. D. Gray, P. H. Gilligan, and W. C. Fowler, Cumitech 13B, Laboratory Diagnosis of Ocular Infections, 2010). The purpose of this practical guidance document is to review, for individuals working in clinical microbiology laboratories, current tools used in the laboratory diagnosis of ocular infections. This document begins by describing the complex, delicate anatomy of the eye, which often leads to limitations in specimen quantity, requiring a close working bond between laboratorians and ophthalmologists to ensure high-quality diagnostic care. Descriptions are provided of common ocular infections in developed nations and neglected ocular infections seen in developing nations. Subsequently, preanalytic, analytic, and postanalytic aspects of laboratory diagnosis and antimicrobial susceptibility testing are explored in depth.

Unilateral Ptosis, Proptosis, and Orbital Myositis After Shingles Vaccination

Vaccinations for shingles are recommended for most adults over 60 years of age and are typically well tolerated. The present case describes acute onset of unilateral ptosis, proptosis, and orbital myositis developing within days after administration of shingles vaccination. The episode resolved to baseline after 1 week of treatment with steroids. To the authors' knowledge, this is first reported case of orbital inflammation following shingles vaccination. Given the temporal relationship and rapid response to treatment, this may represent an autoimmune reaction to the shingles vaccine.

Systemic diseases and the cornea

There is a number of systemic diseases affecting the cornea. These include endocrine disorders (diabetes, Graves' disease, Addison's disease, hyperparathyroidism), infections with viruses (SARS-CoV-2, herpes simplex, varicella zoster, HTLV-1, Epstein-Barr virus) and bacteria (tuberculosis, syphilis and Pseudomonas aeruginosa), autoimmune and inflammatory diseases (rheumatoid arthritis, Sjögren's syndrome, lupus erythematosus, gout, atopic and vernal keratoconjunctivitis, multiple sclerosis, granulomatosis with polyangiitis, sarcoidosis, Cogan's syndrome, immunobullous diseases), corneal deposit disorders (Wilson's disease, cystinosis, Fabry disease, Meretoja's syndrome, mucopolysaccharidosis, hyperlipoproteinemia), and genetic disorders (aniridia, Ehlers-Danlos syndromes, Marfan syndrome). Corneal manifestations often provide an insight to underlying systemic diseases and can act as the first indicator of an undiagnosed systemic condition. Routine eye exams can bring attention to potentially life-threatening illnesses. In this review, we provide a fairly detailed overview of the pathologic changes in the cornea described in various systemic diseases and also discuss underlying molecular mechanisms, as well as current and emerging treatments.

Recurrent Herpes Zoster Ophthalmicus in a Patient With a Novel Toll-Like Receptor 3 Variant Linked to Compromised Activation Capacity in Fibroblasts

BACKGROUND

Herpes zoster ophthalmicus occurs primarily in elderly or immunocompromised individuals after reactivation of varicella zoster virus (VZV). Recurrences of zoster ophthalmicus are uncommon because the reactivation efficiently boosts anti-VZV immunity. A 28-year-old female presented to our clinic with a history of multiple recurrences of zoster ophthalmicus.

METHODS

Whole-exome sequencing (WES), analyses of VZV T-cell immunity, and pathogen recognition receptor function in primary antigen-presenting cells (APCs) and fibroblasts were performed.

RESULTS

Normal VZV-specific T-cell immunity and antibody response were detected. Whole-exome sequencing identified a heterozygous nonsynonymous variant (c.2324C > T) in the Toll-like receptor 3 (TLR3) gene resulting in formation of a premature stop-codon. This alteration could potentially undermine TLR3 signaling in a dominant-negative fashion. Therefore, we investigated TLR3 signaling responses in APCs and fibroblasts from the patient. The APCs responded efficiently to stimulation with TLR3 ligands, whereas the responses from the fibroblasts were compromised.

CONCLUSIONS

We report a novel TLR3 variant associated with recurrent zoster ophthalmicus. Toll-like receptor 3 responses that were unaffected in APCs but diminished in fibroblasts are in line with previous reports linking TLR3 deficiency with herpes simplex virus encephalitis. Mechanisms involving compromised viral sensing in infected cells may thus be central to the described immunodeficiency.

Text-Based Identification of Herpes Zoster Ophthalmicus With Ocular Involvement in the Electronic Health Record: A Population-Based Study

Background

Diagnosis codes are inadequate for accurately identifying herpes zoster ophthalmicus (HZO). Manual review of medical records is expensive and time-consuming, resulting in a lack of population-based data on HZO.

Methods

We conducted a retrospective cohort study, including 87 673 patients aged ≥50 years who had a new HZ diagnosis and associated antiviral prescription between 2010 and 2018. We developed and validated an automated natural language processing (NLP) algorithm to identify HZO with ocular involvement (ocular HZO). We compared the characteristics of NLP-identified ocular HZO, nonocular HZO, and non-HZO cases among HZ patients and identified the factors associated with ocular HZO among HZ patients.

Results

The NLP algorithm achieved 94.9% sensitivity and 94.2% specificity in identifying ocular HZO cases. Among 87 673 incident HZ cases, the proportion identified as ocular HZO was 9.0% (n = 7853) by NLP and 2.3% (n = 1988) by International Classification of Diseases codes. In adjusted analyses, older age and male sex were associated with an increased risk of ocular HZO; Hispanic and black race/ethnicity each were associated with a lower risk of ocular HZO compared with non-Hispanic white.

Conclusions

The NLP algorithm achieved high accuracy and can be used in large population-based studies to identify ocular HZO, avoiding labor-intensive chart review. Age, sex, and race were strongly associated with ocular HZO among HZ patients. We should consider these risk factors when planning for zoster vaccination.

Recurrent Herpes Zoster Ophthalmicus Preceded by Anabolic Steroids and High-Dose L-Arginine

PURPOSE

To report a case of a 34-year-old male with recurrent herpes zoster ophthalmicus (HZO) preceded by a 6-week cycle of anabolic steroids and high-dose amino acid supplementation. Case Presentation. A 34-year-old man presented to our institution for left eye pain for one week associated with a vesicular rash in the V1 dermatome, respecting the midline. The patient had no significant past medical or past ocular history, including systemic immunosuppressive agents or HIV. However, prior to the onset of his symptoms the patient had completed a 6-week course of anabolic steroids including trenbolone, deca-durabolin, and testosterone as well as high-dose arginine supplementation averaging more than 40 grams a day. The best-corrected vision was 20/25 OS with slit-lamp examination remarkable for punctate staining and pseudodendrites at 6 o'clock, outside the visual axis. The patient was treated with oral acyclovir 800 mg five times a day for seven days along with prednisolone QID and moxifloxacin QID which was tapered over a month. Four months after resolution, the patient developed a recurrent HZO keratitis preceded by another cycle of anabolic steroids and amino acid supplementation.

CONCLUSION

In vitro L-arginine supplementation has been associated with the proliferation and virulence of a variety of herpes viruses. Anabolic steroids have also been demonstrated by various studies to negatively affect cell-mediated immunity necessary to prevent viral infection. Thus, it is possible that anabolic steroids in conjunction with increased L-arginine intake may have precipitated a recurrent HZO in a previously healthy, immunocompetent individual.

Herpes zoster of the trigeminal nerve with multi-dermatomal involvement: a case report of an unusual presentation

BACKGROUND

Herpes zoster, also known as shingles, results from reactivation of the varicella-zoster virus. It commonly presents with burning pain and vesicular lesions with unilateral distribution and affects the thoracic and cervical sites in up to 60 and 20% of cases, respectively. The branches of the trigeminal nerves are affected in up to 20% of cases. Multidermatomal involvement of the trigeminal nerves has been only anecdotally described in immunocompetent subjects.

CASE PRESENTATION

A 71-year-old previously healthy male presented with grouped vesicular and impetiginized lesions with crusts on the left half of the face of two-weeks duration. The lesions first developed on the left nasal tip and progressively worsened with unilateral appearance of vesicular lesions on the left forehead, face, ala nasi, nasal vestibulum and columella, as well as on the left side of hard and soft palate. The affected edematous erythematous areas corresponded to the distribution of the left ophthalmic (V1) and maxillary (V2) branches of the trigeminal nerve, including the infraorbital and nasopalatine nerves of the maxillary branch responsible for the oral cavity involvement. Viral DNA amplification by polymerase chain reaction confirmed the presence of Varicella zoster virus. The patient was started on oral valaciclovir with rapid recovery.

CONCLUSIONS

Among immunocompetent patients, herpes zoster is considered a self-limited localized infection. Our observation provides a rare but paradigmatic example of herpes zoster with involvement of both the ophthalmic and maxillary divisions of the trigeminal nerve in an immunocompetent patient. Immunocompetence status and age-specific screening should be warranted in case of atypical involvement and according to the patient's history, while treatment with antiviral drugs should be rapidily initiated in patients at risk.

Herpes Zoster in Kidney Transplant Recipients: A Series of Three Cases

Kidney transplant recipients require lifelong immunosuppression to prevent organ rejection. The need for this intervention, however, leads to decreased cellular immunity and, in turn, increased risk of developing herpes zoster (HZ) from reactivation of latent varicella zoster virus. HZ commonly presents as a painful rash in a dermatome presentation followed by post-herpetic neuralgia. In immunosuppressed individuals, the presentation can be atypical and vary in severity depending on degree of immunosuppression and host immune response. We present the clinical course of 3 kidney transplant recipients who developed HZ after transplantation at different times post-transplant with varying clinical manifestations. The balance between maintaining immunosuppression and preventing or subsequently treating disseminated disease is discussed.

Isolated Internal Ophthalmoplegia Secondary to Herpes Zoster Ophthalmicus: A Rare Case Report

Herpes zoster becomes latent in the sensory ganglia after the primary infection and may reactivate many years later to produce shingles in adults. Involvement of the ophthalmic branch of the trigeminal nerve with this virus is called Herpes zoster ophthalmicus (HZO). The eyelid skin, cornea, uvea, retina, optic nerve and other cranial nerves can be affected by HZO. Isolated internal ophthalmoplegia can rarely be seen. Clinicians should be aware of this condition and HZO must be kept in mind in the differential diagnosis of anisocoria.

Incidence Rate of Herpes Zoster Ophthalmicus: A Retrospective Cohort Study from 1994 through 2018

PURPOSE

To analyze the incidence rate (IR) of herpes zoster ophthalmicus (HZO) and differences by age, gender, race, and region from 1994 through 2018.

DESIGN

Retrospective, observational cohort study.

PARTICIPANTS

Patients with a new International Classification of Diseases, Ninth or Tenth Edition, codes for herpes zoster (HZ) and HZO from January 1, 1994, through December 31, 2018, in the OptumLabs Data Warehouse (OptumLabs, Cambridge, MA).

METHODS

OptumLabs Data Warehouse, a longitudinal, real-world data asset with de-identified administrative claims and electronic health record data, was used to identify enrollees with continuous enrollment in the database for 365 days or more. Patients with no history of HZ or HZO and a new code for HZ and HZO were counted as incident cases. The IR of HZO was calculated by year, 10-year age groups, gender, race, and region.

MAIN OUTCOME MEASURES

Differences in IR from 1994 through 2018 by 10-year age groups and gender.

RESULTS

From 1994 through 2018, 633 474 cases of HZ were reported, with 49 745 (7.9%) having HZO. The incidence of HZO increased from 1994 through 2018 by an estimated 1.1 cases per 100 000 person-years annually (95% confidence interval [CI], 1.0-1.3; P < 0.001). The estimated relative increase was 3.6% annually (95% CI, 3.0%-4.1%). HZO IR increased in all ages over 10 years until 2007, then began declining in individuals younger than 21 and older than 60, stabilizing in individuals 21 to 30 years old, and increasing more slowly among individuals 31 to 60 years old. Men showed an HZO incidence rate ratio (IRR) of 0.74 compared with women. Compared with white patients, the IRRs were 0.70, 0.75, and 0.64 for Asians, black patients, and Hispanics, respectively.

CONCLUSIONS

The incidence of HZO has increased 3.6% per year from 1994 to 2018 in the United States. Since 2008, HZO incidence declined in individuals younger than 21 years and older than 60 years while increasing at a lower rate in middle-aged adults. Given the continued increase, greater efforts should be made to vaccinate eligible adults 50 years of age and older. More research on earlier vaccination is warranted.

Herpes Zoster Ophthalmicus Review and Prevention

Varicella-zoster virus (VZV) is the etiologic agent of both chickenpox and Herpes zoster (HZ). In the United States, there are around one million cases of HZ per year. Ten percent of HZ cases are subtyped as herpes zoster ophthalmicus (HZO) specifically and involve the V1 distribution. Herpes zoster ophthalmicus is a significant cause of blindness in the United States. This article will provide a basic overview of VZV, HZ, and HZO with a focus on preventative measures in an effort to prevent blindness through improving clinician awareness and education. The differences in clinical effectiveness and duration of effectiveness of the live (Zostavax) and recombinant vaccines (Shingrix) are illustrated. There is now a trend toward using the recombinant vaccine as recommended by the Advisory Committee for Immunization Practices (ACIP) for healthy adults 50 or older.

Diabetes as a risk factor for herpes zoster in adults: A synthetic literature review

AIM

The objective of this review was to evaluate the role of diabetes as a risk factor for herpes zoster (HZ) and to discuss implications of prevention by vaccination with available HZ vaccines.

METHODS

We reviewed studies that investigated the incidence rates of HZ in patients with diabetes. Papers in English or French published between January 2000 and December 2018 have been selected from PubMed and Google Scholarship by using appropriate key words.

RESULTS

The risk of HZ was significantly higher in patients with diabetes as compared to controls in 11 studies out of 16, although the magnitude of risk associated to diabetes varied across studies from 1.06 to 2.38 (p < 0.05). The incidence of HZ in patients with diabetes increased with age and was higher in women than in men. The incidence of the most common complication of HZ, i.e. post-herpetic neuralgia was also higher in patients with diabetes.

CONCLUSIONS

The presence of HZ adds supplementary complications to the pre-existing comorbidity in patients with diabetes. Investigating the impact of preventive measure by HZ vaccination is therefore of paramount importance in patients with diabetes.

Anesthesia and Chronic Pain Management

The reasons for development of chronic pain are poorly understood. Chronic postoperative pain is linked to severe acute postoperative pain. Head and neck pain is often a complex phenomenon that requires meticulous diagnosis and treatment. Institution of early multimodal analgesic regimens by multidisciplinary teams may attenuate chronic pain formation and propagation in the otolaryngologic patient.

Herpesvirus Infections of the Nervous System

PURPOSE OF REVIEW

This article reviews the spectrum of neurologic disease associated with human herpesvirus infections.

RECENT FINDINGS

As more patients are becoming therapeutically immunosuppressed, human herpesvirus infections are increasingly common. Historically, infections with human herpesviruses were described as temporal lobe encephalitis caused by herpes simplex virus type 1 or type 2. More recently, however, additional pathogens, such as varicella-zoster virus, Epstein-Barr virus, cytomegalovirus, and human herpesvirus 6 have been identified to cause serious neurologic infections. As literature emerges, clinical presentations of herpesvirus infections have taken on many new forms, becoming heterogeneous and involving nearly every location along the neuraxis. Advanced diagnostic methods are now available for each specific pathogen in the herpesvirus family. As data emerge on viral resistance to conventional therapies, newer antiviral medications must be considered.

SUMMARY

Infections from the herpesvirus family can have devastating neurologic outcomes without prompt and appropriate treatment. Clinical recognition of symptoms and appropriate advanced testing are necessary to correctly identify the infectious etiology. Knowledge of secondary neurologic complications of disease is equally important to prevent additional morbidity and mortality. This article discusses infections of the central and peripheral nervous systems caused by herpes simplex virus type 1 and type 2, varicella-zoster virus, Epstein-Barr virus, cytomegalovirus, and human herpesvirus 6. The pathophysiology, epidemiology, clinical presentations of disease, diagnostic investigations, imaging characteristics, and treatment for each infectious etiology are discussed in detail.

Headache and vision changes in an elderly man with rheumatoid arthritis

We present a case of an elderly, immunosuppressed patient with rheumatoid arthritis who was not appropriately vaccinated, and subsequently developed herpes zoster ophthalmicus, which initially presented similar to giant cell arteritis. Evidence-based vaccinations are integral in decreasing the incidence of preventable diseases and promoting optimal health at the individual and population level. Although the patient ultimately did not suffer any long-term adverse sequelae, this case highlights the importance of vaccination in the rheumatology setting, and to consider both inflammatory and infectious causes of headache and vision changes in the elderly.

Does Herpes Zoster Increase the Risk of Stroke and Myocardial Infarction? A Comprehensive Review

Herpes zoster (HZ) caused by varicella zoster virus (VZV) reactivation is characterized as a vesicular rash of unilateral distribution that can also cause multiple complications; such as post-herpetic neuralgia; ophthalmic zoster; and other neurological issues. VZV can also increase incident hemorrhagic or ischemic complications by causing inflammatory vasculopathy. Thus; emerging epidemiological and clinical data recognizes an association between HZ and subsequent acute strokes or myocardial infarction (MI). This study reviewed published articles to elucidate the association between HZ and cerebrovascular and cardiac events. Individuals exposed to HZ or herpes zoster ophthalmicus had 1.3 to 4-fold increased risks of cerebrovascular events. Higher risks were noted among younger patients (age < 40 years) within one year after an HZ episode. The elevated risk of CV events diminished gradually according to age and length of time after an HZ episode. The putative mechanisms of VZV vasculopathy were also discussed. Several studies showed that the development of herpes zoster and herpes zoster ophthalmicus increased the risks of stroke; transient ischemic attack; and acute cardiac events. The association between VZV infection and cardiovascular events requires further studies to establish the optimal antiviral treatment and zoster vaccination to reduce zoster-associated vascular risk

Post-herpes neurotrophic keratopathy: Aetiopathogenesis, clinical signs and current therapies

Neurotrophic keratopathy (NK) is a degenerative corneal disease caused by damage of trigeminal innervation. This leads to epithelial defects, ulceration and, eventually, perforation. Both herpes simplex and varicella zoster keratitis are reported to be the main causes of NK. Furthermore, prognosis in this type of NK is poor. Classic clinical findings in post-herpes NK are spontaneous epithelial breakdown, round and central epithelial defects with smooth edges, stromal melting and thinning, scarring, and neovascularisation. Although several medical and surgical treatments have been reported, no therapies are currently available to definitely restore corneal sensitivity. Therefore, NK remains a challenging disease to treat. In this review a summary is presented of the pathogenesis, manifestations, and current management of post-herpes NK. The role of antiviral treatment and varicella-zoster vaccination is also discussed. A description is also presented on both medical and surgical novel therapies, such as regenerative drugs and corneal neurotization.

Complications of herpes zoster in immunocompetent older adults: Incidence in vaccine and placebo groups in two large phase 3 trials

BACKGROUND

An adjuvanted herpes zoster (HZ) subunit vaccine, HZ/su, demonstrated high efficacy against HZ and postherpetic neuralgia (PHN) in two randomized, observer-blind, placebo-controlled trials in adults aged ≥50 and ≥70 years (ZOE-50 and ZOE-70, respectively).

METHODS

Data from ZOE-50 and ZOE-70 trials were analyzed to evaluate the efficacy of HZ/su against mortality, hospitalizations, and non-PHN complications of HZ including HZ-associated vasculitis, stroke, and disseminated, ophthalmic, neurologic, and visceral diseases.

RESULTS

In the pooled ZOE-50/ZOE-70 analysis, 1 of 32 HZ/su recipients (3.1%) and 16 of 477 placebo recipients (3.4%) with a confirmed HZ episode had complications other than PHN. Efficacy against HZ-related complications was 93.7% (95% confidence interval, 59.5-99.9%) in adults aged ≥50 years and 91.6% (43.3-99.8%) in adults ≥70 years. Five HZ-related hospitalizations, all in placebo recipients, and no HZ-related deaths were reported.

CONCLUSIONS

HZ/su reduces the risk of HZ-associated complications in older adults (NCT01165177; NCT01165229).

Herpes Zoster in the Older Adult

Herpes zoster (HZ) is the result of reactivation of latent varicella zoster virus (VZV) and occurs most frequently in older adults. Classically, HZ presents as a unilateral, selflimited, dermatomal rash. Postherpetic neuralgia (PHN) is a common sequela, presenting as severe pain that persists after the rash has resolved. In the elderly, PHN can be debilitating and requires a prompt diagnosis, treatment with antivirals, and adequate pain control. A longer-term pain management strategy is required if PHN occurs. A modestly effective vaccine exists and is recommended for older individuals.

A systematic review and meta-analysis on herpes zoster and the risk of cardiac and cerebrovascular events

Background

Patients who develop herpes zoster or herpes zoster ophthalmicus may be at risk for cerebrovascular and cardiac complications. We systematically reviewed the published literature to determine the association between herpes zoster and its subtypes with the occurrence of cerebrovascular and cardiac events.

Methods/Results

Systematic searches of PubMed (MEDLINE), SCOPUS (Embase) and Google Scholar were performed in December 2016. Eligible studies were cohort, case-control, and self-controlled case-series examining the association between herpes zoster or subtypes of herpes zoster with the occurrence of cerebrovascular and cardiac events including stroke, transient ischemic attack, coronary heart disease, and myocardial infarction. Data on the occurrence of the examined events were abstracted. Odds ratios and their accompanying confidence intervals were estimated using random and fixed effects models with statistical heterogeneity estimated with the I² statistic. Twelve studies examining 7.9 million patients up to 28 years after the onset of herpes zoster met our pre-defined eligibility criteria. Random and fixed effects meta-analyses showed that herpes zoster, type unspecified, and herpes zoster ophthalmicus were associated with a significantly increased risk of cerebrovascular events, without any evidence of statistical heterogeneity. Our meta-analysis also found a significantly increased risk of cardiac events associated with herpes zoster, type unspecified.

Conclusions

Our results are consistent with the accumulating body of evidence that herpes zoster and herpes zoster ophthalmicus are significantly associated with cerebrovascular and cardiovascular events.

Red Eye: A Guide for Non-specialists

BACKGROUND

Red eye can arise as a manifestation of many different systemic and ophthalmological diseases. The physician whom the patient first consults for this problem is often not an ophthalmologist. A correct assessment of the urgency of the situation is vitally important for the planning of further diagnostic evaluation and treatment.

METHODS

This review is based on pertinent publications retrieved by a selective literature search in PubMed in August 2016 as well as on the authors' own clinical and scientific experience.

RESULTS

Primary care physicians typically see 4-10 patients per week who complain of ocular symptoms. Most of them have red eye as the major clinical finding. A detailed history, baseline ophthalmological tests, and accompanying manifestations can narrow down the differential diagnosis. The duration and laterality of symptoms (uni- vs. bilateral) and the intensity of pain are the main criteria allowing the differentiation of non-critical changes that can be cared for by a general practitioner from diseases calling for elective referral to an ophthalmologist and eye emergencies requiring urgent ophthalmic surgery.

CONCLUSION

The differential diagnosis of red eye can be narrowed down rapidly with simple baseline tests and targeted questioning. Patients with ocular emergencies should be referred to an ophthalmologist at once, as should all patients whose diagnosis is in doubt.